Not much information has come our about the PEMEX drilling rig accident. A new article says that 21 people were killed and that production should be resuming soon. Most reports seem to blame the weather. That doesn’t seem to be an adequate root cause analysis. Perhaps more information will be released later.
It was a bad day for Del Monte Fresh Produce and American Staffing Resources. Oregon OSHA came to investigate a complaint and left behind $28,700 in fines.
I don’t know anything about this crash but I found it while looking for the most recent Dash-8 crash in denmark. Don’t know what it is about aitplane crashes that make them so interesting … but I guess it’s like going to the dirt track stock car races and watching the pile-ups. You hope people don’t get hurt but you just can’t stop watching.
A press release from the US Chemical Safety Board:
Washington, DC, October 29, 2007 - Two investigators from the U.S. Chemical Safety Board (CSB) are deploying to the site of today’s fire at the Barton Solvents facility in Des Moines, Iowa.
The CSB is currently investigating a solvent fire that heavily damaged a Barton Solvents distribution facility in Valley Center, Kansas, causing the evacuation of thousands of residents and sending projectiles into the surrounding community.
Lead investigator Randy McClure, who is also leading the Kansas-based investigation, will be accompanied by investigator Jim Lay, P.E. The investigators will begin examining the circumstances and causes of the fire in Des Moines, which reports say forced an evacuation and the closure of major roadways.
The CSB is an independent federal agency charged with investigating industrial chemical accidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.
The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Visit their website at http://www.csb.gov.
For more information, contact Director of Public Affairs Dr. Daniel Horowitz, 202-261-7613, cell 202-441-6074.
It was a bad day for Scandinavian Airlines. One of their Bombardier-built Q400 turboprops (Dash 8-400s) slide down the runway on its belly after the landing gear collapsed.
Even though no one was seriously injured in this or the previous accidents, the third accident makes one wonder about the root cause analysis of the first two accidents and the decision to resume flying the aircraft.
When accidents become repetitive, they could cause the investigator to look into the “Management System - Corrective Action - corrective action needs improvement” category on the Root Cause Tree®.
SAS grounded its turboprops “until further notice.” Let’s hope that the next root cause analysis performed by Bombardier and SAS find the real root causes and stop this problem before a real tragedy occurs.
To read the AP story on the most recent crash see:
In an amazing settlement and statement, BP spent $50 million to end the criminal investigation into the corporation’s role in the Texas City Refinery Explosion by agreeing to plead guilty to one felony count under the Clean Air Act. The money will go to the US Treasury. I guess that we now know the price for ending a government investigation into a corporation’s role in the death of 15 people. A little over 3 million per life.
However, this settlement left junior employees (operators, supervisors, and middle managers) out in the cold. The Houston Chronicle says that U.S. Attorney Don DeGabrielle of Houston said:
“…different individuals were aware of different risks and either failed to convey concerns to others or failed to fix substandard equipment.”
“Supervisors, management people, operators were aware of things that were going on, and had they paid attention to their requirements under the Clean Air Act, had they repaired safety systems in their own plant that were defective or not operating at all, this horrific tragedy could have been prevented.”
This statement by the US Attorney seems to focus blame at those at the pointy end of the stick with the least resources to defend their actions.
Will the US government really prosecute operators, supervisors, and plant management? My guess is that those at the pointy end of the stick don’t have $50 million to settle their charges … so only time will tell.
The Associated Press reports that the NTSB is focusing on several potential causes of the I-35W bridge collapse.
Contributors to the collapse that are under investigation include:
- a rusted gusset plate
- corroded and debris filled roller bearings
- a design issue
- weight on the bridge
- the contribution of the 91ºF heat that day
How long will it take for the NTSB to complete their accident investigation? The article reports that the agency says it could take another 12 to 18 months. Hardly the instant root cause analysis results needed by 24 hour news coverage.
When something goes wrong on a ship - fire the CO! That’s conventional wisdom in the US Navy. And it has been since the days of sail.
On October 23, I reported on the USS Hampton’s incident where the ship’s ELTs (Engineering Laboratory Technicians) were reportedly falsifying the records of their daily analysis of the reactor’s chemistry. According to the AP story, this didn’t just happen once, but rather for a whole month (or more).
My guess was that the Commanding Officer (CO) and the Engineer (the person in charge of the department that runs the reactor) would lose their jobs.
Now another AP story has confirmed my guess. The CO has been relieved of his command. (Fired in civilian terminology.)
Will a thorough root cause analysis of this incident be conducted? It seems the corrective actions (punishment for the crew and firing of the CO) has already occurred, so don’t hold your breath.
The firings have already occurred, the crew will be retrained, and a tough new CO will be brought aboard to make sure this never happens again. All they would need to do is to write a new procedure and they will have covered all the standard corrective action bases that we joke about in TapRooT® Courses.
Club Car (a subsidiary of Ingersoll-Rand) is looking for a Senior Mechanical Design Engineer with root cause analysis skills. For more information see:
The year is rapidly coming to a close. Do you still have training dollars to spend?
Why not INVEST those dollars in training that will pay dividends for years to come:
TapRooT® Root Cause Analysis Training
There are still a few dates open in late November and early December. If you would like to schedule a course at your facility, call 865-539-2139 or click here and write us a note.
Reuters reported that Impala Platinum, the mines owner, announced that the shaft in which the accident occurred would be shut until the investigation is complete.
The Associated Press reports that 18 people died and 7 are still missing after Usumacinta jackup rig (owned by Perforadra Central) was damage in a collision with the Kab 101 light-oil production platform during a storm in the Gulf of Mexico. The rig was drilling a well close to the production platform.
UK Rail Accident Investigation Board (RAIB) has published a root cause analysis investigation report on the derailment at Birmingham Snow Hill on Midland Metro on January 29, 2007.
Recent outbreaks of E coli contamination in the US food supply has caused the press to start reporting on food safety. However, the increased press reports don’t seem to be enough to get the attention of all executives at companies supplying food to the US market.
points out the danger food processors face if they ignore warning signs.
What can happen? When management misses the warning signs and fails to fix the root causes of minor problems, then major accidents, product recalls, and operating difficulties are just around the corner. According to the information in the article, failure to act on smaller problems caused a major outbreak of food-borne illness, a major recall of their product (ground beef patties), and bankruptcy of the company (owned by the private equity firm Strategic Investments & Holdings since 2003). If only management at Topps had understood the use of advanced root cause analysis to analyze and solve problems, they could have prevented this E coli outbreak and saved the company from bankruptcy.
What does this have to do with your company? Try asking these questions and see what answers you get:
What would a major recall cost your company? Could your company survive?
Does your management know how to use advanced root cause analysis to spot problems and improve performance?
Does your company spot problems when they are small and use what they can learn from a thorough root cause analysis to prevent major problems?
Would your management like to learn how to keep major accidents from happening by applying known best practices?
For more information about training your management, call System Improvements at 865-539-2139 or click here and drop us a note.
But don’t wait too long and let disaster strike your company.
The Associated Press reports that Usumacinta jackup rig (owned by Perforadra Central) was damage in a collision with another structure during a storm in the Gulf of Mexico.
The article makes it sound as if a fatal jousting accident is a freak accident. But using horses to charge at each other with wooden poles (even if they have balsa wood tips) sounds like a pretty risky activity.
A miner received a head injury during a rock slide at a mine. Because of hospital “downgrades”, emergency treatment was delayed. The article and the ABC web site states:
“The groundswell of anger is becoming quite near to a boiling point I think. People have just had enough.”
How do six sailors give the entire Nuclear Navy a black eye? Simple … Falsify the results of required chemistry checks for a nuclear reactor. And do it not just once or twice … but for an entire month.
I spent 7 years in the Nuclear Navy (back in the late 70’s and early 80’s). I find the idea of not sampling the reactor chemistry for a month … amazing! Admiral Rickover is probably spinning in his grave!
From the story it sounds like they were somehow caught during their ORSE (Operational Reactor Safeguards Exam). Surely this resulted in a failed ORSE. The Commanding Officer and Engineer will be looking for new jobs (probably outside the Navy - their naval careers are ruined).
Once again, if lax enforcement of standards (especially sampling of reactor chemistry) can happen in the Nuclear Navy … poor enforcement of SPAC can happen anyplace.
What are you doing to enforce important policies?
Are you just using late-uncertain-negatives?
Have you tried soon-certain-positives?
If you don’t know what I’m talking about you should consider attending the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. It has a section on changing behavior that will teach you what you need to know.
For course information, dates/locations, and registration see:
The Rail Accident Investigation Branch (RAIB) has released its report into a fire on a HGV shuttle in the Channel Tunnel on August 21, 2006. The RAIB has made sixteen recommendations as a result of the report.
On August 29-30 a real nuclear weapon was shipped across country in a B-52. This wouldn’t be news except for one problem … It was supposed to be a just a missile with no nuclear weapon attached.
The Associated Press article said that the mistake occurred when people handling the weapon decided not to use a “complex schedule” under which they track the disarming, loading, and moving of weapons. Instead, the airmen had invented their own “informal” system.
Air Force Secretary Michael Wynne said:
“This was an unacceptable mistake and a clear deviation from our exacting standards. We hold ourselves accountable to the American people and want to ensure proper corrective action has been taken.”
The Air Force conducted a six-week investigation into the cause of the accidental shipment. The main corrective action reported by the Associated Press story was punishment of 70 Air Force personnel.
The story says that highest ranking personnel punished are four officers who were relieved this week of their commands. This includes the 5th Bomb Wing commander at Minot, Col. Bruce Emig, who also has been the base commander since June.
65 airmen have been decertified from handling nuclear weapons. The certification process looks at a person’s psychological profile, any medications they are taking and other factors in determining a person’s reliability to handle weapons.
What lesson can everyone learn from this procedural failure? You don’t get strict compliance with lax enforcement. I’m not sure that the Air Force corrective actions are adequate, but this certainly sounds like a Management System - Standards, Policies, and Administrative Controls (SPAC) Not Used - Enforcement Needs Improvement root cause.
If you have high risk systems, enforcement of procedure use has to be a high management and supervisory priority, or standards will slip.
They pushed-back their 737 jet from the gate and hit a barrier. It knocked a hole in the jet, grounding the flight.
Should accidents like this happen? Absolutely not! Time for a root cause analysis by the airline to see where their practices failed to produce a safe, high quality experience for their passengers.
Reuters reports that a crane dropped a container of debris from the 53rd floor of a signature skyscraper under construction. After the accident, four construction workers and three pedestrians were treated for minor injuries. For more info see:
A 1998 failure of the nose wheel steering actuator is at the cetre of a contoversy around Lockheed’s Jetstar corporate aircraft. For more information see:
Quality Managers need to get to the root causes of quality issues and audit findings. And old techniques like fishbone diagrams and 5-whys just aren’t going to cut it when they need reliable answers in high tech / high risk industries that need exceptionally good quality.
If you need to learn about the premier root cause analysis technology - TapRooR® - then attend a 2-Day or 5-Day course. For more information, see the TapRooT® web site.
I saw a recent story in the Singapore News with the following quote:
Mr Chew’s brother-in-law, Mr Peh Eng Hup, said: “I heard that debris had piled up on the 17th floor. Maybe it was too heavy for the slab, so it gave way, and he happened to be below. But who’s responsible, no one knows.” Police and the Manpower Ministry are investigating the incident.
Again, responsibility and blame are the first thoughts - (instead of finding the root cause that can be - a should be - corrected to prevent these kinds of accidents).
Lesson Learned: Stop looking for who to blame and start looking for what needs to be improved.
Even better, look for improvements BEFORE acidents happen and become proactive!
Why should maintenance and engineering professionals attend Equifactor® Training? Because employers are looking for for people with advanced troubleshooting and root cause analysis skills.
The Houston Chronicle reports that a six month internal BP review conducted by the new CEO has found “organizational complexity” as the cause of their operational and safety problems.
What can you do in the local area? I’d suggest visiting Warwick Castle!
Or visit the Woodland Grange web site for more information on the local area. The Woodland Grange training facility is just a cab ride away from the Birmingham airport.
You know I’m for good investigations and through root cause analysis of accidents with complete analysis of the Management System and any regulatory failures. And I think we all should have access to the results of government investigations. But the press is asking for access to a current - ongoing - MSHA investigation. I believe that kind of access is unprecedented and harmful. See if you agree…
MSHA is performing a root cause analysis of the Crandall Canyon Mine disaster. CNN, the Associated Press, the Salt Lake Tribune, the Denver Morning News and others filed a joint suit to STOP the investigation until a judge could decide whether the proceedings (the investigation) should be open to the public (see CNN story).
First, stopping a safety investigation by MSHA so that the press can see if they can be included seems totally outlandish to me. The CNN story makes it sound as if MSHA is covering up its mistakes and only the spotlight that the press can shine on an investigation will save the day and make MSHA come clean. And if the judge doesn’t see it like CNN sees it … the Congress should intervene! After all, it is CNN’s First Amendment (freedom of speech? - that’s their claim) right to have open access to the investigation.
Imagine being an investigator doing an investigation and having to bring the press along. If you think people (company owners, miners, and even MSHA employees) are reluctant to talk openly about their mistakes now, imagine if what they said was going to be the headlines in the morning paper (or on CNN) the next day.
Fortunately, the judge - U.S. District Judge Dee Benson - had better sense and looked at the Constitution. He wrote:
“Plaintiffs argue that the First Amendment mandates public access to the type of MSHA [Mine Safety and Health Administration] proceeding at issue in this case … They point, however, to nothing specific in the Constitution to support their claim.”
Good call Judge Benson!
How does CNN play this decision? They said:
“The press does not have the right to get access to the government’s investigation into the deadly August accident at the Crandall Canyon mine, a federal judge in Utah ruled Tuesday.
U.S. District Judge Dee Benson said there is no constitutional basis for him to make the investigation public.”
By the way, the press - just like everyone else - will have access to the COMPLETED investigation. MSHA posts fatality investigation reports on their web site and has a PRESS conference about major investigations when they are complete. The difference in this case is that the press has decided that they should be allowed to see the internal workings and raw data of the investigation.
Too me … that seems nuts!
Don’t get me wrong. I’m not naive. I know that government regulatory agencies - just like anyone else - doesn’t like to put their mistakes on public display. And there may be regulatory shortcoming in the mining permits that were approved for this mine. But the investigation and MSHA should be judged on their openness and honesty after the investigation is complete.
DISCLOSURE:
In the fairness of disclosure … MSHA is a TapRooT® User. We also have a former MSHA employee as one of our instructors.
That has nothing to do with my belief that this request is nuts. But if I don’t disclose it … someone could say I was just trying to protect a client.
However, rather than protecting a client, I think I’m protecting self-critical analysis, investigations, and root cause analysis.
I firmly believe that the press does little to shine light on the root causes of disasters. (For example - Katrina.)
The press should wait - like everyone else - for the investigation to be finished. Then they can criticize MSHA for not being self-critical enough IF that turns out to be the case.
Otherwise, I believe that total press access to an ongoing, detailed investigation would turn the investigation into a Hollywood press circus. The MSHA investigation of the Crandall Canyon Mine disaster would look more like the OJ Simpson trial.
I’m convinced, a politicized, instant answer press investigation won’t help improve mine safety - or safety anywhere. Their methods and time line just won’t allow it.
